What is the recommended medication regimen for Rapid Sequence Intubation (RSI) in the pediatric population?

Recommended Medication Regimen for Pediatric Rapid Sequence Intubation (RSI)

For pediatric rapid sequence intubation, the recommended medication regimen includes a sedative-hypnotic agent (ketamine or etomidate) followed by a neuromuscular blocking agent (succinylcholine or rocuronium), with atropine pretreatment for children under 8 years of age. 1

Pretreatment Medications

• Atropine should be administered during induction and before intubation for children aged from 28 days to 8 years, particularly in those with septic shock, hypovolemia, or when succinylcholine is used 1
• Recommended atropine dosing: 0.01-0.02 mg/kg IV (maximum: 0.5 mg) 1
• Atropine helps prevent bradycardia that can occur during laryngoscopy or from succinylcholine use in pediatric patients 2

Sedative-Hypnotic Agents

• Ketamine is recommended as a first-line agent for pediatric RSI, especially in hemodynamically unstable patients 1

  • Dosing: 1-2 mg/kg IV 1, 3
  • Advantages: Maintains hemodynamic stability through sympathomimetic effects 3
  • Considerations: May cause increased salivation (can be managed with atropine) 1

• Etomidate is an alternative first-line agent, particularly useful in patients with head injury 1

  • Dosing: 0.2-0.4 mg/kg IV (maximum: 20 mg) 1
  • Advantages: Minimal hemodynamic effects, lowers intracranial pressure 1
  • Considerations: May cause transient adrenal suppression, though this is rarely clinically significant 1

Neuromuscular Blocking Agents

• Succinylcholine is the first-line neuromuscular blocking agent for RSI in pediatric patients with respiratory or cardiovascular compromise 1

  • Dosing: 1-1.5 mg/kg IV for children >10 years; 1.2 mg/kg for children 1-10 years; 2.0 mg/kg for infants 1 month to 1 year; 1.8 mg/kg for neonates <1 month 2
  • Advantages: Rapid onset and short duration of action 2
  • Contraindications: History of malignant hyperthermia, muscular dystrophies, immobilization >3 days, hyperkalemia 2

• Rocuronium is recommended when succinylcholine is contraindicated 1

  • Dosing: 0.9-1.2 mg/kg IV 1, 4
  • Advantages: Similar intubating conditions to succinylcholine at higher doses 1
  • Considerations: Longer duration of action (30-60 minutes) compared to succinylcholine 4
  • Sugammadex should be rapidly available when rocuronium is used for potential reversal if needed 1

Special Considerations

• For patients with increased intracranial pressure:

  • Consider lidocaine 1-2 mg/kg IV as a single dose 30 seconds to 5 minutes before airway instrumentation 1
  • Etomidate may be preferred as the induction agent due to its ICP-lowering effects 1

• For hemodynamically unstable patients:

  • Ketamine is preferred over other induction agents due to its relative hemodynamic stability 1, 3
  • Use the lower end of the dosing range (1 mg/kg) to minimize potential adverse effects 3

• RSI success rates:

  • RSI has been shown to have higher first-attempt success rates (78%) compared to intubation without medications (47%) or with sedation alone without neuromuscular blockade (44%) 5

Common Pitfalls and Caveats

• Failure to administer atropine in young children, particularly when using succinylcholine, increasing the risk of clinically significant bradycardia 1, 2
• Underdosing rocuronium (doses <0.9 mg/kg) may result in suboptimal intubating conditions 1
• Inadequate post-intubation sedation and analgesia when using non-depolarizing NMBAs like rocuronium, potentially leading to awareness during paralysis 6
• Using succinylcholine in patients with contraindications such as hyperkalemia, which can lead to cardiac arrest 2, 6
• Failure to have sugammadex available when using high-dose rocuronium, which may be needed in a "can't intubate, can't ventilate" scenario 1, 3

By following this evidence-based approach to pediatric RSI, clinicians can maximize the chances of successful intubation while minimizing complications and adverse outcomes.